International Research Journal of Engineering and Technology (IRJET) Volume: 09 Issue: 05 | May 2022
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e-ISSN: 2395-0056 p-ISSN: 2395-0072
Evaluation of the medical records documentation completeness Dr. R. Latha1, Dr. Xavier Pravin Marshall2 1Head
of the Department, Department of Hospital Administration, Dr.N.G.P. Arts and Science College 2Student, Department of Hospital Administration, Dr.N.G.P. Arts and Science College ---------------------------------------------------------------------***--------------------------------------------------------------------data registration in the medical record will result in the Abstract - All health providers must document their
loss of diagnostics and additional costs to patients. In the age of information and technology, medical records are the most important, real and rich source of medical and medical information because they are based on medical facts. As some medical forms are considered to be the most focused forms of patient record and have specific significance such as a summary paper, medical history sheet, continuation note; if they are not in medical records or are incomplete they may result in incorrect diagnosis during hospitalization and even after discharge from the patient. In addition, the complete and complete maintenance and upkeep of medical records is an important part of patient medical management. One of the most important reasons for incomplete records is that doctors and surgeons believed that the medical care or surgery required of patients was important, but datarelated documentation was not considered part of their treatment process. a misconception because the time spent on registering and completing patient health records is considered part of the care process. The quality of medical records reflects the quality of health care provided by physicians, and an effective system of medical records facilitates the evaluation and research of health care.
medical records as a legal and professional responsibility. They contain information on all elements of the patient's care. Despite the importance of medical records in supporting better quality health-care services, poor recording is fairly widespread all across the world. 1. INTRODUCTION Medical record documents are an important legal and professional requirement for all health professionals. Despite its importance, there has been little research available that evaluates the overall level of medical records of health professionals. As medical records are a great source of health information, they are essential for maintaining accurate, varied and accurate patient data. They include relevant facts, findings, and observations of a patient's health history including past and present illnesses, trials, laboratory tests, treatments, and outcomes. Medical records, manually or electronically, include information, which describes all aspects of patient care. Doctors, nurses, and other health care providers need medical knowledge to get treatment for patients. These resources mediate relationships between physicians, patients, and other health care providers. Health information results in legal protection for the patient, healthcare providers or hospitals if necessary or problematic. In addition, medical records play a major role in providing financial goals and shaping treatment costs and supporting medical education, health care services, and medical research Well-designed medical records and related clinical documentation procedures allow hospitals and doctors in addition to health authorities and decisionmakers to have accurate records of their records. existing status by considering the accuracy and compliance with the maintenance of medical records. International law requires that all actions related to medical services be fully and accurately recorded. The record should be made whenever a health care service is started and this includes all tests, diagnoses, treatments, and nursing care. Medical records are important tools for effective treatment and prevention. In addition, they play a key role in speeding up the process and improving treatment, evaluating the effectiveness of medical staff and nurses, organizing a medical / health organization and making appropriate and important decisions. In addition, the adjustment of hospital patient reports helps physicians to plan for patients' treatment, as well as diagnostics. Incomplete
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2. Objective of study: All health providers must document their medical records as a legal and professional responsibility. They contain information on all elements of the patient's care. Despite the importance of medical records in supporting better quality health-care services, poor recording is fairly widespread all across the world.
3. Type of the study and sampling: This is a descriptive cross-sectional study in which 268 medical records of inpatients were included for analysis from January to March 2022. The sample comprised reviewing the medical records of all patients admitted to the four main wards between January 2022 and March 2022 (General internal medicine, General surgery, paediatrics, Obstetrics/Gynecology Ward). The internal medicine ward had 90 records, the general surgery ward had 127, the paediatrics ward had 23, and the Obstetrics/Gynecology ward had 28.
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